With more than 8,000 confirmed, suspected and probable cases of Ebola and nearly 4,000 deaths, mainly in Guinea, Liberia and Sierra Leone, the impact of this Ebola outbreak far surpasses all previous outbreaks registered since the disease was identified in 1976. But what type of crisis is this? Is this just another humanitarian crisis in a year unusually crowded with emergencies, or is it also a serious crisis of humanitarian governance?
What kind of crisis is this?
In popular culture and current media coverage, Ebola is often portrayed more as a civilisational crisis than a humanitarian one: the fear-mongering and alarmist outbreak narratives, including frequent allusions to Zombies, are reminiscent of the early coverage of HIV/AIDS in the mid-1980s. The racial connotations are equally familiar but much older: the blaming of victims for their primitive food habits (bush meat), irrational customs (burial practices) and hostility to modern medical practice (including sorcery and physical attacks on health workers) has the ring of Joseph Conrad’s Heart of Darkness about it. Africa is yet again a diseased place, with ambiguous relationships between animal and man and the living and the dead.
But Ebola is a humanitarian crisis. It is occurring in post-conflict countries with corrupt and ineffective governments, where inadequate basic health care, food insecurity and poverty made life difficult long before Ebola came along. As noted by one commentator, the spread of Ebola has little to do with the characteristics of the virus. Over the last couple of months, families of sick individuals have tried to care for patients without even the benefits of running water or a safe place to dispose of waste. A disinfectant such as chlorine and plastic gloves are simply unaffordable for many. Left without access to treatment due to overburdened or abandoned health facilities, many succumb to the old scourges of African ill-health, such as malaria and tuberculosis. These deaths are not counted in official statistics on Ebola deaths, although they are results of the outbreak. Orphaned children are not taken in by their extended family due to fear of transmission of the disease. Schools are closed in many areas, with serious consequences for development and social stability far into the future. Food shortages are becoming a serious problem.
Ebola as a crisis of humanitarian governance
Patient Zero is thought to have died in Guinea in December 2013. By March 2014, Médecins Sans Frontières (MSF) had launched an emergency response to the outbreak. However, the organisation had difficulty in getting anyone to listen, and in enlisting volunteers to go to the field. Other organisations felt overwhelmed by emergencies elsewhere. In August the World Health Organisation (WHO) finally declared Ebola an international health emergency, and in September the UN declared it a threat to international peace and security. What the international community has not done, however, is to set the humanitarian cluster system in motion: until October, MSF was almost alone in the field.
Moving towards a humanitarian response
The response by national governments has included quarantining slums (Liberia); imposing a countrywide lockdown (Sierra Leone); closing international borders (Côte d’Ivoire and Senegal); and the mass cancellation of flights to West Africa. As Ebola crosses the borders of developed countries, these responses are giving way to a massive medical relief effort. Since the Ebola emergency will be with us for the foreseeable future, it is worth reflecting critically on the humanitarian response. Here’s my five cents’ worth.
What do we do with numbers and how do we get them?
As in any epidemic, numbers must be obtained. At the moment, however, we don’t even know what we know: in its 8 October 8 situational report, WHO stated that the fall in reported cases in Liberia is unlikely to be genuine, and rather reflects a collapse in the ability to gather data. How extensive is the underreporting? And what consequences will the lack of data have? At the moment Nigeria appears to be a success story, but will this last? On a more general level, why did no early warning system pick this up and sound the alarm? In light of the vocal MSF warnings coming out of the region, is this not a problem of data at all?
Still valuing lives differently
The attention and resources lavished on Western Ebola patients is a stark reminder of how differently life is valued according to place of origin. It also demonstrates that being in a well-equipped hospital in the developed world increases your chances of survival significantly. Meanwhile, as Western countries evacuate their citizens the non-Western staff of humanitarian organisations and the frontline medical staff of the Sierra Leone, Liberia and Guinea are not evacuated. Systematic evacuations are not a panacea and would undoubtedly generate other problems. However, progress is slow on a promised hospital to treat health care workers in Liberia and it seems uncertain whether this facility is intended for foreign health care workers only.
From military medical capacity to militarised humanitarianism?
On 2 September, MSF asked for military medical capacity to be deployed to deal with the growing crisis. The question is whether this will result in the militarisation of humanitarian medical aid. US President Barack Obama has deployed AFRICOM to Liberia, and in Sierra Leone the British military is planning a 62-bed facility in coordination with Save the Children. Can the Western military degrade and destroy Ebola? Are we seeing the rise of Ebola as a vehicle for soft power? What are the consequences of framing the response to Ebola as an issue of national security? Commentators note that security responses by their very nature are not meant to be transparent: there will be few ways for ordinary Liberians to know exactly what is going on as facilities are constructed and put to use, and for the general public to assess the effectiveness of the response.
Ultimately, the battle against Ebola only has one long-term solution. If this is an unprecedented public health crisis, the answer must be unprecedented investment in basic public health structures. This includes not only training local public health workers to respond to deadly outbreaks, and maintaining a high-quality surveillance and response system, but also investing more in basic health services overall.
In all probability as the crisis subsides there will be an avalanche of harsh evaluations across the humanitarian enterprise, followed by some ritual soul-searching. Particular criticism must attach to WHO. In a certain sense, a UN organisation is only as good as its member states want it to be. WHO has dealt with massive funding cuts and has lost many of its best staff. Nevertheless, the organisation’s slow response and lack of early leadership mean that heads must roll.
The Ebola crisis is a story with thousands of anonymous and unsung local heroes. At present, the only institutional humanitarian hero appears to be MSF, which is having one of its finest hours. Nevertheless, there will also be fallout for this organisation. Its call for a military medical response and its collaboration with the US military will have consequences. This is a crisis where MSF has found neutrality and independence too costly. However, the question is whether MSF is placing too little currency on these hard-won virtues. There is little doubt that the organisation will change as a result of Ebola, but whether it faces a longer-term existential crisis remains to be seen.
This blog was inspired by discussions at the PRIO/NCHS breakfast seminar Ebola: A Humanitarian Crisis or a Crisis of Humanitarian Governance, held in Oslo on 7 October 2014. I am grateful to Sarah Pettersen and all the participants. This blog represents my views alone, and all errors and omissions remain my own.